Business Briefs: The Business Side of Infusion Therapy: An Interview with a Coding Expert

Information regarding coding, coverage, and payment is provided as a service to our readers. Every effort has been made to ensure the accuracy of the information. HMP Communications and the authors do not represent, guarantee, or warranty that the coding, coverage, and payment information is error-free and/or that payment will be received. The responsibility for verifying coding, coverage, and payment information accuracy lies with the reader.   Business Briefs has previously addressed the importance of attention to business details. With more hospital-based outpatient wound care departments (HOPDs) adding infusion services, our readers can benefit from learning the business from a leading authority on infusion therapy coding, Andrea Clark, RHIA, CCS, CPH, chairman, CEO, founder of Health Revenue Assurance Associates, Plantation, FL.   Q: When an HOPD is considering adding infusion therapy services, which reference sources are recommended to learn how to code properly?   A: Look to the following references:     • CPT®¹ Manual, along with instructions     • CPT® Assistant (2007 to present)     • National Correct Coding Initiative Policy Manual instructions     • Federal Register Final HOPPS Rules     • Centers for Medicare and Medicaid Services (CMS) Frequently Asked Questions (https://questions.cms.hhs.gov)     • Medicare Administrative Contractors and Fiscal Intermediaries Local Coverage Determinations (LCDs) and Questions/Answers     • CPT® Knowledge Base — American Medical Association (www.ama-assn.org)     • HCPCS Coding Clinic — American Hospital Association (www.ahacentraloffice.com)     • Medicare Claims Processing Manual — Chapter 4, Section 230.2 (Coding and Payment for Drug Administration)   Q: When a patient with a chronic wound receives care from a physician in the HOPD, the patient and the payer typically receive two bills: one from the physician and one from the HOPD. Infusion therapy services appear to be performed by the HOPD staff. Does the physician also bill for the service?   A: No, physicians do not bill (96360–96379, 96401, 96402, 96409–96425, and 96521–96523) when those services are performed by the HOPD. The physician’s work related to hydration, injection, and infusion services typically consists of affirmation of the treatment plan and direct supervision of the staff. If the physician performs an Evaluation and Management (E/M) service for a significant, separately identifiable problem, the physician should report the appropriate E/M code.   Q: Must clinical documentation include start and stop times for infusion?   A: Yes, time units are calculated based on how long the fluids have infused. The documentation must include both the start and stop times to justify the amount of time billed and the amount of revenue received. Let me emphasize that time-based CPT® codes require time frame documentation. Failure to provide documentation of minutes to support billed units could result in revenue reversal.   HOPDs should report the CPT® codes that describe the actual time over which the infusion is administered to the patient for time-specific drug administration codes. HOPDs should not include in their reporting the time that may elapse between establishment of vascular access and initiation of the infusion. HOPDs should read the CPT® Manual for specific instructions regarding reporting time for various types of infusions.   Q: When the HOPD starts an IV or accesses a port when providing drug-administration services, can the HOPD bill separately?   A: No, starting an IV or accessing an IV or port is considered integral to the drug administration, and therefore neither is separately reportable. Do not report 36000 (Introduction of needle or intracatheter, vein) or 36410 (Venipuncture, age 3 years or older, necessitating physician’s skill) [separate procedure,] for diagnostic or therapeutic purposes (not to be used for routine venipuncture) for IV infusion, injection, blood administration, or chemotherapy.   Q: When is hydration considered medically necessary, and how should it be coded?   A: Codes 96360–96361 are intended to report a hydration IV infusion to consist of a pre-packaged fluid and electrolytes only. The codes are not used to report infusion of drugs or other substances.   Q: What medical documentation is required to support medical necessity for administering hydration?   A: Medical necessity is supported in the evaluation performed by the provider (usually on the same day) and involves the clinical assessment of the patient. Documentation of the assessment should describe symptoms warranting hydration (such as those associated with dehydration, the inability to ingest fluids, abnormal fluid losses, abnormal vital signs, or abnormal laboratory studies, and the like). Nausea itself does not implicate fluid volume depletion, nor does it support necessity for fluid repletion.   It is important to distinguish the medical necessity of hydration from the use of fluid administration intended only to keep the vein open. When the sole purpose of the IV fluid administration is to maintain vascular access or patency of the IV line, the service is neither diagnostic nor therapeutic and should not be separately reported on the claim. Keep Vein Open (KVO), Heparin/Saline Lock is not considered a hydration service and will not support the use of 96360 or 96361.   Q: Is physician order necessary for hydration services, and is there a certain rate to confirm medical necessity?   A: Yes, a valid physician order for hydration is required to support the service as reasonable and necessary. A specific rate alone does not necessarily support hydration. CMS has adopted the definition of services and has applied these definitions whenever possible. The CPT® Manual does not distinguish by the number of mL per hour. However, to qualify as medically necessary hydration, the rate of infusion should support performance of this service for rapid replenishment.   Q: If a patient is infused with saline concurrently with an infusion of a nonchemotherapy drug, can hydration be billed separately?   A: Hydration can be billed separately only if it is given before or subsequent to the infusion and is >30 minutes. If hydration fluid is provided to facilitate drug delivery, it is considered incidental to that infusion and is not separately billable.   Administration of fluid during a transfusion or between units of blood products to maintain IV line patency is incidental hydration and is not separately reportable.   Q: Which infusion code(s) should be used for administration of antibiotics, steroidal agents, analgesics, and the like?   A: The administration of those infused medications independently or sequentially should be reported with 96365, 96366, 96367, and/or 96378, as appropriate.   Q: If an order is for an antibiotic to be infused piggyback to normal saline, is this considered hydration or therapeutic?   A: Therapeutic, prophylactic, or diagnostic IV infusion codes (96365, 96366) should be reported for administration of substances/drugs. In this instance, the substance infused is the antibiotic. The first hour of infusion is reported using 96365. The add-on code 96366 is reported once for each additional hour of infusion. Hydration codes 96360 and 96361 are not used to report infusion of drugs/substances.   Q: There are different CPT® codes as follows: 96366 — each additional hour; 96367 — additional sequential infusion of a new drug/substance, and 96368 — concurrent infusion. Please explain how to use these codes appropriately.   A: Sequential infusions are an infusion of a different drug immediately following the initial drug. The clinician should report CPT® 96367 for the first hour, which is 16–60 minutes, per CPT® guidelines. For 2012, sequential narrative has added the wording “new drug/substance,” which is different from the past. The clinician should report 96366 for additional hour(s), or >30 minutes for either 96365 or 96367. Clinicians must clearly document the time each drug was put up/started and what time each drug infusion ended. Concurrent infusions are multiple infusions (different drugs) provided simultaneously through the same intravenous line or given at the same time. In order to report 96368, the drugs cannot simply be mixed in one bag; there must be more than one bag. If the drugs are mixed in the same bag, only the initial infusion (ie, 96365) should be reported. If the drugs are being infused at the same time in two different bags, an initial infusion code (ie, 96365) and the concurrent code (ie, 96368) should be reported.   Q: When administering multiple infusions, can the HOPD report each infusion as the “initial” service code?   A: No, hierarchies have been created to determine which service should be reported when more than one type of infusion service is provided. The hierarchies vary depending on whether the physician or the HOPD is reporting. The physician’s hierarchy is based upon the physician knowledge of the clinical condition(s) and treatment(s): the “initial” code is the one that best describes the key or primary reason for the encounter, irrespective of the order in which the infusions occur. The HOPD’s hierarchy is based upon a structural algorithm and clear instructions to assist with code reporting.   The following hierarchy is based on the highest to lowest service regardless of the order in which they occurred. When administering multiple infusions, injections, or combinations, only one “initial” service code should be reported for a given date of service:     • Chemotherapy and other highly complex drug or biologic agent services       o Initial infusions primary to IV pushes     • Therapeutic, prophylactic, and diagnostic services       o Initial infusions primary to IV pushes     • Hydration services.   Intramuscular and subcutaneous injections do not have hierarchy rules and can be reported as many times as ordered, resulted, and documented.   Q: When multiple drugs are administered, can the HOPD report each of the products?   A: Yes, they are reported with HCPCS codes typically from the pharmacy charging structure.   Q: Do you have any parting advice?   A: When beginning infusion programs, documentation is key to properly reporting infusion codes. Code reporting becomes easier with clear, concise documentation that includes physician orders, specific diagnosis(es), and the appropriate start and stop times of the infusion therapy. Timed CPT® codes demand a documented time frame to ensure revenue integrity and to uphold revenue. 1. CPT is a registered trademark of the American Medical Association.   Kathleen D. Schaum, MS, is President and Founder of Kathleen D. Schaum & Associates, Inc., Lake Worth, FL. Ms. Schaum can be reached for questions and consultations by calling 561-964-2470 or through her email address: kathleendschaum@bellsouth.net.   Andrea Clark, RHIA, CCS, CPCH, is chairman, CEO, and founder of Health Revenue Assurance Associates, Plantation, FL; email: aclark@hraa.com.